Circulation Journal Vol.78, August 2014 Circulation Journal
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evidence of embolic events.
Because of uncontrolled infection and the possibility of pus spreading out into the cardiac structures, we decided to proceed with operation. After resection of the mass with AML, mitral valve was replaced by mechanical prosthetic valve. There was a septated space in the mass. The space was open to the left ventricular side. Histopathology showed suppurative inflam- mation of the mass (Figure 2).
Infective endocarditis caused by P. aeruginosa in patients without i.v. drug use is extremely rare.
2There have been few data on the complications due to P. aeruginosa infective en- docarditis. In the present case, an abscess pocket was formed in the vegetation, and this was clearly identified on 3D-TEE.
Echocardiography plays a fundamental role in the diagnosis of infective endocarditis, complication recognition, and thera- peutic decision making.
33D-TEE additionally provided detailed anatomic information,
4–6and therefore has increased useful- ness in identifying infective endocarditis lesions and their complications.
To our knowledge, the present case of P. aeruginosa infec- 51-year-old woman with end-stage renal disease was
admitted with a 1 month history of general weakness and persistent fever. Chronic diabetic foot ulcer was noted on the right heel with calcaneal exposure. Blood and wound cultures had grown Pseudomonas aeruginosa (P.
aeruginosa).
Transthoracic echocardiography indicated a hypoechoic and homogenous round mass on the left atrial (LA) side of the an- terior mitral leaflet (AML), suggesting vegetation. To evaluate associated complications, transesophageal echocardiography (TEE) was done. The 1.4 ×1.6-cm mass was attached on the LA side of the A3 portion of the AML. The presence of a central halo was noted in the mass. Given that mitral valve aneurysm is frequently associated with infective endocarditis,
1more de- tailed anatomic information was needed for a differential di- agnosis. Three-dimensional TEE (3D-TEE) confirmed the pocket formation in the mass (Figure 1). The echocardiograph- ic findings suggested abscess pocket formation in the vegeta- tion, rather than mitral valve aneurysm. Inside the pocket, there was no evidence of thrombus formation. Also, there was no
A
Received January 29, 2014; revised manuscript received March 31, 2014; accepted April 9, 2014; released online May 21, 2014 Time for primary review: 26 days
Department of Cardiology (J.-S.P., B.-J.C., S.-Y.C., M.-H.Y., G.-S.H., S.-J.T., J.-H.S.), Department of Thoracic and Cardiovascular Surgery (Y.-S.H.), Ajou University School of Medicine, Suwon, Korea
Mailing address: Joon-Han Shin, MD, Department of Cardiology, Ajou University School of Medicine, 164 Worldcup-Ro, Suwon, Korea, 443-380. E-mail: [email protected]
ISSN-1346-9843 doi: 10.1253/circj.CJ-14-0111
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Abscess Pocket in the Vegetation Confirmed on 3-Dimensional Transesophageal Echocardiography
Jin-Sun Park, MD; You-Sun Hong, MD; Byoung-Joo Choi, MD; So-Yeon Choi, MD, PhD;
Myeong-Ho Yoon, MD, PhD; Gyo-Seung Hwang, MD, PhD;
Seung-Jea Tahk, MD, PhD; Joon-Han Shin, MD
Figure 1. (A) Two-dimensional transesophageal echocardiography showed a round mass attached on the left atrial (LA) side of the anterior mitral leaflet (AML). A central halo was noted in the mass. (B) Three-dimensional echocardiography (3DE) showed a round mass on the LA side of the A3 portion of the AML. (C) Cropping into the 3DE acquisition showed the abscess pocket in the mass. LV, left ventricle.
IMAGES IN CARDIOVASCULAR MEDICINE
Circulation Journal Vol.78, August 2014
1996 PARK JS et al.
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tive endocarditis complicated with abscess pocket formation in the vegetation, confirmed on 3D-TEE, is the first to be re- ported in the literature.
Acknowledgments The authors have no conflicts of interest to disclose.
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Left-sided Pseudomonas aeruginosa endocarditis in patients without
Figure 2. (A) Resection of the anterior mitral leaflet with vegetation. (B) The vegetation contained a septated ab- scess pocket inside. (C) There was a small hole on the left ventricular side of the abscess pocket. (D) The septated space was open to the left ventricle.
(E,F) On histopathology suppurative in- flammation of the mass was seen (H&E;
E, ×40; F, ×100), including neutrophil in- filtration, fibrinous exudates, granulation tissue and bacterial colonies (black ar- rows), which were compatible with ab- scess pocket.
